Patient Survey

It is our goal to give you the best possible medical care. To do so, it is important that we know your thoughts about the care you are receiving. We need to know what we are doing right and in what areas we can improve. Your comments will be strictly confidential. Space is provided at the end of this survey for any additional comments you may wish to make. Thank you for your assistance.

1. Today's Date:

2. I am a:

First-time patientReturning patient

3. Your Provider's Name:

4. Why did you choose this office for your medical treatment?

4a. Please specify:
4b. Name of referring physician:

5. How long did it take to get your initial appointment?

6. Was this time frame acceptable to you?


7. Please describe your initial telephone call:

7a. Was this a reasonable amount of time to be on hold?: YesNo

8. After you arrived, how long did you have to wait to see your physician?

9. Was this amount of time acceptable to you?


10. Would you refer a family member or a friend to our office?


Please rate our practice in terms of:

11. Ease of use of our automated phone system:
12. Your experience with the person who answered your call:

12a. Enter name of staff member if known:
13. How you were treated when you arrived at the reception desk?

13a. Enter name of staff member if known:
14. Adequate assistance in completion of any forms
15. Notification from staff if the physician was running behind/late
16. Patient education material provided
17. The comfort of the waiting room
18. Experience/interaction of/with the medical assistant

18a. Enter name of assistant if known:
19. Physician interest in your problem
20. Physician explanation of your illness and treatment
21. The explanation of your options, cost, fitting of Durable Medical Equipment (such as braces or slings provided)
22. The amount of time the doctor spent with you
23. Overall experience with Physical/Occupational Therapy
24. Your experience with X-Ray tech

24a. Enter name of tech if known:
25. Level of satisfaction with the medical treatment you received
26. Your check-out experience
27. Test results reported in a reasonable amount of time
28. The helpfulness of the individual helping with billing and/or insurance

28a. Enter name of staff member if known:
29. The ability to contact us after hours
30. What is your overall rating of our practice?
Name: (optional)
Telephone: (optional)
Comments or Suggestions: